Volume 5, No. 4 Winter 1990-91
Table of Contents

Patient Safety Again Highlighted at ASA: 86 Abstracts in Scientific Sessions
Monitors and More Shown in Exhibits
Editorial: APSF Comes of Age, Works for Safety
APSF Awards Three Research Grants at Annual Meeting
Ellison C. Pierce, Jr. Award Winner Announced for 1990
Anesthesiologists' Claims, Insurance Premiums Reduced: Improved Safety Cited
Reporters Ask Safety Questions During ASA 'Media Tour'
ASA Closed Claims Study Tallies 8 Publications
Anesthesia Techs Form National Society
APSF Survey Reveals Long Work Hours in Anesthesia
Letter to the Editor
Symposium for Operating Room Team to Be Held in May

Patient Safety Again Highlighted at ASA: 86 Abstracts in Scientific Sessions

by Stanley J. Aukburg, M.D.; Hugh C. Gilbert, M.D.; William D. Owens, M.D.; Susan L. Polk, M.D.;

Jeffery S. Vender, M.D.; and Gerald L. Zeitlin, M.D.

Strong interest in research on issues associated with anesthesia patient safety was again seen in the scientific sessions at the 1990 American Society of Anesthesiolosists' Annual Meeting. In the four half-day presentations under "Patient Safety, Epidemiology, and Education,"(two oral and two poster), 86 abstracts were offered. Summarized here are only some of the many interesting papers having direct relevance to patient safety. Several other presentations, including some regarding education, also had links to patient safety considerations.

Decreasing Anesthesia Cardiac Arrests

Drs. R. L. Keenan and C. P. Boyan compared the incidence of cardiac arrest during anesthesia in the decades 1969-78 and 1978-88 at the Medical College of Virginia to see if increased safety awareness and enhanced monitoring* have made a difference. The rate of cardiac arrest decreased. Cardiac arrest due in part or totally from anesthesia fell from 2: 10,000 to 1: 10,000 from the first to the second decade studied at this institution. This improvement was due entirely to a decrease in the preventable respiratory category, from an incidence of 0. 84: 10,000 to 15: 1 0,000. Cardiac arrests judged to be unpreventable or preventable nonrespiratory incidents did not change significantly when comparing the two decades. The proposed favorable influence of pulse oximetry was further emphasized by the fact that both of the two preventable respiratory incidents leading to arrest in the latter decade occurred before pulse oximetry was introduced in 1984, but the incidence was decreasing before then as well. The nonrespiratory preventable causes were vaporizer errors or overdoses of inhaled agents in most cases, but included two cases of hyperkalemia and one instance of hypotension due to spinal anesthesia.

Equipment Failure and Misuse

Dr. M. E Vistica and her colleagues from the University of Washington in Seattle examined the role of equipment as a cause of damaging events and adverse outcomes. The data base originated with the A.S.A. Closed Claim Study and consisted of 67 malpractice claims (out of 1, 54 1) in which equipment was implicated as causing a negative outcome. Misuse of equipment was implicated in 57% of these, while 13% were due to equipment failure and 30% were unknown. Catheters, ventilators, and anesthesia machines were the most frequently misused. Breathing system disconnect was the most commonly identified adverse event. "Payments in these closed claims ranged from $430 to $3,500,000 with 70% of all equipment-related claims resulting in payment. following presentation of the paper, there was considerable discussion about "misuse" of the terms "failure" or I " misuse" Since the end result is statistically the same in terms of payout, the semantics seem to be less important than the result.

Stress in the Attending Anesthesiologist

Dr. J. S. Naulty and colleagues from George Washington Medical Center reported on stress in attending anesthesiologists. Specifically, faculty members were monitored by cardiac monitors while supervising two junior or two senior residents to ascertain. Whether specific events can trigger stress; 2. Whether the true level of the residents influences the perceived level of stress; and 3. If this perceived stress correlates with ST segment changes or dysrhythmias. Attending anesthesiologists less than 50 years of age reported perceived stress more frequently when supervising junior than when supervising senior residents, although heart rate changes were more frequent when supervising senior residents. Attendings over 50 years of age reported a low frequency of perceived stress than younger attendings, regardless of the training level of the residents. The older attendings were able to correlate cardiac changes and perceived stress better than the younger attendings. Perhaps these differences are due to greater experience acclamation, or physiologic alterations associated with maturing in the older attendings.

Failure of Pulse Oximetry

Dr. B. S. A. Gillis and colleagues from the University of Washington examined and reported on the "failure' rate of pulse oximetry in a PACU location. They accumulated pulse oximetry monitoring data on 2,937 patients. The pulse oximetry was said to have failed when there were two or more 15-minute periods when no values were noted. Using that criterion, the overall failure to display saturation values was approximately 1% with the majority (90%) of these failures at the beginning of the PACU stay. This rate compares favorably to the previously reported failure rate of 0.77% in the operating room. Since these failures of display of pulse oximeters in the PACU were probably at least in part due to emergence delirium and shivering, it was suggested that there may well be a "physiologic" problem with the patient when the device is "failing" to pickup and display pulse oximetry saturation values.

Preventing Transmission of Blood-Borne Infections

Prevention of transmission of AIDS, hepatitis, and other blood-borne infections was also the subject of a study by Dr. E. S. Greene of the Albany Medical Center, who offered arguments for the adoption of national standards of practice for infection control. Use of drugs from multidose vials for more than one patient was cited as a practice that should be abandoned. Among his suggestions for new measures that might reduce transmission of blood-borne disease was the adoption of needleless systems for intravenous administration of drug boluses and infusions.

Implementation of Infection Control Precautions

Dr. A. Rosenberg and colleagues from the Hospital for Joint Diseases Orthopedic Institute and the New York University Medical Center reported a follow-up of a 1989 abstract. They surveyed 653 attendees at a major meeting for infection-related perceptions and practices associated with anesthesia cam Although aware of hepatitis and HIV hazards, there was little improvement in the conduct of their practices. Forty-nine percent of anesthesia personnel still reused vasopressor syringes and 63% still reused common drug syringes. This compared to 47% and 6 1 %, respectively, in 1989. This was done despite 79% of the respondents believing that needles do get contaminated when injecting solutions into I.V. tubing. Fortunately, the investigators report some improvement in the wearing of gloves(47% in 1989 and 79% in 1990), vaccination against hepatitis (53% vs. 6 1 %), and recapping of needles (79% vs. 86%). While there has been some improvement in self-protection on measures, the data indicate that this is not so for patient-to-patient protective maneuvers. It was concluded education must continue.

Transfusion Risks

Dr. Rosenberg and others also retrospectively reviewed records of 233 patients undergoing total hip replacement to determine the most effective method for avoiding the risks induced by homologous blood transfusion in the perioperative period. They found that predonation of two units of autologous blood combined with intraoperative use of the Cell Saver and postoperative reinfusion of shed blood resulted in 96% of the patients avoiding homologous transfusion. Unless the patients had significant cardiovascular disease they were allowed a hematocrit as low as 20% before homologous blood was administered. Postoperative coagulopathy resulting from retransfusion of shed blood was treated with fresh frozen plasma when necessary.

Aspiration Risk

At the Mayo Clinic, Drs. 1. G. Weber, M. A. Warner and M. E. Warner found the incidence of pulmonary aspiration in 105,364 consecutive general anesthetics over three years to be 1:2509 (4: 10,000). Aspiration was rigidly defined as the presence of bilious or particulate material in the tracheobronchial tree. Significant risk factors were emergent cases, age less than two years, and higher ASA physical status classification. Of those 42 patients who did aspirate, one died on the table for other reasons, 26 (62%) developed no symptoms and had no sequelae, and the remaining 15 (36%) were monitored and treated in the intensive care unit for hypoxia and/or pneumonitis. Ten of those required mechanical ventilation. Six patients developed non-bacterial ARDS, two of whom died, and one patient developed Klebsiella pneumonitis. As a direct result of this study, the Mayo Clinic will now discharge from the PACU any patient who has not developed either hypoxemia, wheezing, coughing or radiographic abnormalities within two hours of clinically apparent aspiration.

Gas Machine Failure Detection

In an attempt to evaluate machine checkout habits with and without the use of the FDA checklist, Drs. M. G. March and J.J. Crowley from George Washington University utilized a traveling exhibit of two types of anesthesia machines with a total of eight faults that could be variably introduced. They tested 166 volunteer anesthesiologists on the machine of their choice. The study design called for the anesthesiologist to perform his own checkout procedure on a machine with four previously set faults, then to use the FDA checkout list to repeat his checkout after four different faults mere incorporated into the machine. A short multiple choice quiz was then administered, in order to correlate accuracy of checkout with knowledge about the specific faults. With only one of the faults, the N20-02 ratio override failure, did use of the FDA checklist improve performance significantly. The checklist appeared not to aid the volunteers in finding any other fault. Them was no significant correlation between finding faults and the type or length of practice, or with results on the quiz. The authors suspected that the FDA checklist was not of aid in finding most faults because the volunteers did not use it correctly, and suggest that machine and equipment "failures" might become less frequent as contributors to anesthesia incidents if that checklist is modified to make it mom "user friendly" and if anesthesiologist could be educated to implement correct checkout procedures.

Air Embolism Detection

Dr. J.J. van der Aa and colleagues for the University of Florida evaluated a prototype expert system in diagnosing air embolism as the cause for acute decreases in end-tidal C02 in sheep. Information from monitors of airway pressure, expiratory flow, expired C02, inspired gasses, ventilator settings, and pulse oximetry is fed into the expert system, executed on an IBM-PC/AT, and combined with individual patient data to pinpoint circuit disconnects, leaks, overventilation, or decreased C02 production as causes for abrupt changes in ETCO2. The system correctly identified air embolism without false positives or false negatives in every instance, and did so before alarms on the front-end monitors called attention to the situation. It was also efficient at picking up other causes of acute ETC02 changes, such as mainstem intubation, leaks, and changes in ventilation. The authors concluded that this expert system could be helpful in ruling out other causes of sudden hypocapnia, enhancing the anesthesiologist's early response to the situation.

Inadequate Pre-Op ECG Evaluation

Dr. R. L. Wollman and colleagues from the Medical College of Virginia compared anesthesiologist's ECG evaluations to official readings in all patients presenting for anesthesia at another institution over a two week period. They found that 6 1 % of ECGs did not have an official reading at the time the patient came to surgery, and the anesthesiologists' interpretation of the ECG differed from the cardiologists' eventual reading of 55.4%. Depressingly, of the ECGs that did have official readings on the chart, the anesthesiologists either failed to note the reading or recorded a different interpretation in 36.7%. In 34.7% of patients presenting without an official reading and 26.3% with a reading, anesthesiologists made errors that were judged "clinically important," many involving acute ischemia and potentially leading to poor patient outcomes. The authors concluded that cardiologists are obligated to provide timely ECG interpretations on preoperative patients, and that anesthesiologists should be careful to review and document official ECG interpretations.

Evaluating "Mental Workload"

Dr. D. M. Gaba and T. Lee at Stanford University utilized a computerized random presentation of two digit addition problems to measure the mental workload of the anesthesiologist during the course of administering anesthetics in the operating room. Nine residents were tested during the administration of 19 anesthetics, and were instructed to put their patient care tasks first at all times. Delay in answering the problem or skipping them was interpreted as indicating that the resident was busy at other tasks. An independent observer recorded what the residents were doing at the time of presentation of the problems, announced by a beep on the computer. Delay or skipping was most commonly associated with performance of manual tasks, followed in order by attending interaction, conversation, and recording. 13% of the delays were associated with "doing nothing" indicating that mental activity alone is also a defined workload. The authors pointed out that this study reinforces the findings of Cooper, et. al. that teaching in progress in the operating room can be distracting and even a contributing factor in anesthetic incidents and, thus, may impact negatively on patient safety. This methodology could be utilized in comparing workload in different types of surgeries and anesthetic techniques, among different practitioners, and in measuring the effects of stress, fatigue, automation, and alarms on the anesthesiologist's vigilance .

Allergic Reactions to Anesthetic Drugs

Dr. G. Occelli and colleagues, Hospital Saint-Roch, Nice Cedex, France, demonstrated that skin testing accurately predicted potential allergic reactions in a group of patients who have had a life-threatening anaphylactic reaction to anesthetic medications, both confirming sensitivity to the suspect drug from the past and accurately demonstrating lack of reaction to other medications that were used to subsequently administer uneventful anesthetics. This study suggests that skin testing of patients at risk for allergic reactions can identify potential drug reactions and aid anesthesiologists in their drug choices.

Airway Management

Drs. J. T. Roberts, H. H. Ali and G. D. Shorten from the Massachusetts General Hospital advocate using a bubble inclinometer to aid in evaluation of the airway. This inexpensive device was found to be helpful in determining laryngeal tilt which the authors believe correlates with graded scales of difficulty in using a #3 MacIntosh laryngoscope blade to visualize the larynx.

A prospective study from West Germany (Dr. A. Deller et. al.) suggests that the devastating consequences of airway difficulties can be minimized if anesthesia personnel carefully evaluate mobility of the cervical spine and any anatomic abnormalities of the face, neck and teeth. 8,2 84 patients were evaluated and 2 54 could not be intubated on the first attempt. I 0 1 patients proved difficult on repeated attempts. The most common predictors among these patients were facial anatomic abnormalities, difficulty visualizing the pharyngeal structures with maximal mouth opening, and a small mouth orifice.

Dr. R. Glassenberg and associates from Northwestern University noted a statistically not-significant decline in failed intubations for Caesarean sections from 11300 to 1/500 after the introduction of the fiber optic Laryngoscope. They suggest there may be an irreducible minimum number of failed intubations and note that half the cases occurred in women with normal appearing airways, and, therefore, were not anticipated

Anesthetic Catastrophe

Drs. R. L. Keenan, 1. H. Shapiro, and K. Dawson of the Medical College of Virginia analyzed their institution's incidence of cardiac arrest in infants. There were 4,343 cases over eight years about evenly divided between anesthesiologists with and without pediatric fellowship training or equivalent. The pediatric anesthesiologists had no cardiac arrests in infants whereas the rate for the other group of anesthesiologists was 19 arrests per 10,000 patients. It was concluded that the attendance of pediatric anesthesiologists significantly decreased anesthetic morbidity in infants.

Drs. H. Schwid and D. O'Donnell of the University of Washington advocate the use of an on-screen computerized anesthesia simulator to give clinicians experience in the early diagnosis and treatment of malignant hyperthermia. Four case scenarios have been developed to allow anesthesiologists working at the simulator to observe the triggers, physiologic changes, and results of therapeutic intervention in MH model cases.

Sleep deprivation in anesthesia personnel was found to have an adverse impact on costive tasks. This study was performed by Drs. J. Zelcer, J. Manton, and J.D. Paull (Royal Women's Hospital, Melbourne). Seventeen third-year registrars were evaluated during a 24 hour period when each of them stayed awake, whether they were working or not. Each subject also acted as his or her own control, being studied at another time during a normal daytime duty cycle when well rested. As one might expect, measurements of subjective phenomena such as fatigue and sleepiness increased. The results of objective tests of logical reasoning and short term memory worsened after 18 hours of wakefulness and this decrement achieved statistical significance at 24 hours. This work confirms that performance on tasks involving attention span, vigilance, problem-solving ability, short-term memory, information retrieval, and reasoning is negatively affected by 18-24 hours of continual work without sleep. As these are the skills involved in administering anesthesia, the patient safety implications are clear. The authors hypothesized that these measured deteriorations might contribute to increased probability of anesthetic mishaps caused by human error.

Postoperative Drinking and Driving

Dr. J. L. Lichtor and associates from the University of Chicago investigated whether patients having ambulatory surgery obeyed instructions about drinking alcohol or driving within 24 hours of anesthesia or intravenous sedation. They found that 11 of 37 patients either drank, or drove themselves, but none did both, within 24 hours.

In a further study, the same investigators asked the question, "Does it matter?" They performed a placebo-controlled, double blind study on volunteers, giving them either intravenous saline or fentanyl with midazolam. Four hours later the same subjects drank a beverage that either did, or did not contain alcohol. The subjects completed a set of psychomotor performance tests before, during and after this sequence. It was concluded that the effects of short-acting drugs used in ambulatory surgery had probably dissipated by the time the patient arrived home, and so would be unlikely to potentiate or interact with alcohol.

Critical Incident

Intraoperative carbon monoxide toxicity(peak levels of CO Hb of 12-29%) was demonstrated in three patients underpins enflurane anesthesia. While the exact cause or causes of this CO accumulation remain unknown, Dr. R. E. Moon and colleagues (Duke University Medical Center, Durham) noted that this very unusual CO accumulation occurred each time in the risk case on Monday morning. Thorough investigation led to circumstantial evidence suggesting the C02 absorbent or anesthesia circuit as the source, possibly the result of some slow low-grade chemical reaction over the week-end. This report underscores the importance of flushing anesthesia circuits prior to their use

Non-Cognitive Factors Play a Major Causal Role in Critical Incidents

M. F Rhoton, Ph.D. and her colleagues from Case Western Reserve University investigated the role of non-cognitive variables in the genesis of critical incidents involving anesthesia residents. They identified lack of conscientiousness and loss of composure as being most frequently associated with critical incidents. In contrast, an inadequate knowledge base was rarely identified as a causative factor.

Drs. A. DeAnda, D. M. Gaba, and I Lee continued their studies of anesthesiologists' responses to critical incidents using a comprehensive anesthesia simulator. This time they studied an "experienced" group of private practitioners and faculty members and compared these results to the previous findings in a group of residents. Their subjects were presented with six simulated problems; short circuit hoses, a kink in an IV fine, endobronchial intubation, atrial fibrillation, airway disconnection and a cardiac arrest. They then measured the response times for detection and the beginning of definitive correction of these problems. With some exceptions, there was more rapid detection and correction with increasing physician experience. This was particularly true when first year residents were compared with all others. However, even within the experienced group, there was marked variability, particularly in the appropriateness of the response to the simulated cardiac arrest.

Blinded Study of Pulse Oximetry

Dr. J.T. Moller and colleagues of Herlev Hospital in Copenhagen, Denmark presented a fascinating study that would be difficult to duplicate in the USA Using pulse oximetry, they compared the incidence and duration of hypoxia, in both the recovery room and the operating room, between a group of patients in which the saturation values were available to care-providing personnel and a group in which the values were blinded from the care providers. It was considered feasible to attempt this study m Denmark because pulse oximetry had not yet become a de-facto standard of care them The investigators found the incidence and duration of episodes of hypoxemia were significantly less in both the operating room and the recovery room when oxygen saturation values were available to the caregivers. They also found that hypoxemia was more frequent, more severe, and more prolonged in the recovery room than in the operating room. Their findings strongly support the value of pulse oximetry in risk reduction during anesthesia. Moreover, they indicate that oxygen saturation monitoring should continue during recovery from anesthesia.

Is MAC Safer Than General or Regional for ESWL?

Anesthesiologists often state their belief that for many procedures local anesthesia is not inherently safer than general or regional anesthesia. This belief was supported by the results of a study of post-procedure morbidity in ESWL patients. This study by Drs. A.L. Kovac and J.V. Mangold of the University of Kansas revealed a higher incidence of post-procedure pain, hypertension, and nausea and vomiting with monitored anesthesia care than with general or regional anesthesia.

Drs. Owens (Washington University, St. Louis) and Polk (University of Chicago)moderated ASA scientific sessions. Drs. Aukberg (University of Pennsylvania), Vender [assisted by Dr. Gilbert] (Evanston (IL) Hospital), and Zeitlin (Lahey Clinic, Burlington, MA) are members of the APSF Newsletter Editorial Board and reported on the poster sessions.

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Monitors and More Shown in Exhibits

by John H. Eichhorn, M.D.

Patient Safety related technology and concepts were prominently featured in the technical and scientific exhibits at the October ASA Annual Meeting.

As has been the case in the last three years, existing forms of patient monitoring appeared in new "mix-and-match" 'combinations while there was comparatively little in the way of genuinely new technology. A random survey of pricing policies suggest that there is more manufacturer/ dealer discounting-and flexibility this year and, thus, this may be a relatively good time for capital investments in monitors.

Within the category of monitors, respiratory gas and volatile agent monitors continue to be featured prominently. Several new versions and brands were shown for the first time. Less specific emphasis on the potential safety impact of these instruments was seen this year compared to) last year. Several prototypes of equipment for measuring blood gas and pH monitoring, both intermittent and continuous, were exhibited. Various technologies involving other than traditional electrodes are involved and each manufacturer seems confident of having solved (each in a different way) the potential problem of clot or serum protein obstruction of the device-blood interface. Each company suggested commercial availability "soon."

'Real Time' NIBP

More attempts at non-invasive continuous real-time waveform blood pressure monitoring were demonstrated. One involves a small air bladder that compresses the radial artery against the underlying bone and functions as a tonometer. Another (which is zeroed against a traditional cuff involves somewhat the same concept with a piezoelectric crystal partially compressing the artery and then measuring arterial wall motion. Still another continuous blood pressure monitor shown in prototype last year senses pressure (after zeroing with a standard cuff) by comparing pulse wave velocity* and volume at two separate sites (usually finger and forehead). This latter instrument also can have reflectance plethysmograph/pulse oximetry incorporated.

Respiratory Sensors

Piezoelectric crystals also are the heart of a self contained wireless remote respiratory monitor that senses chest wall movement. The manufacturer claims a minimum of motion artifact because only the bidirectional equal volumes of the chest wall are recognized by the computer. The unit can also sense ECG and can transmit both via radio signals to a base unit. This technology is -suggested for epidural (pain therapy, labor, etc.) and PCA patients.

Hot Finger

There was significant emphasis on temperature monitoring and a wide variety of technologies to prevent heat loss and/or rewarm cold patients. A related concept was the demonstration of a mitten made of heat reflecting fabric intended for use enclosing a hand with a pulse oximeter probe in place on a finger. The goal is to prevent or relieve cold-induced vasoconstriction that can inhibit correct pulse oximeter function while at the same time shielding out potentially interfering ambient light.

At least three new versions and improved existing models of computers automated anesthesia records/patient information data managers were exhibited. Each will connect to existing monitoring equipment and capture patient -monitor output readings automatically at the programmed interval. Other details, such as compatibility with hospital mainframe computers, varied widely. All these manufacturers agreed, however, that they predict dramatically increased interest in and application of this type of technology.

New types of endotracheal tubes for use in laryngeal laser surgery and tubes made of new materials were shown. Each was touted as an advance in the quest for freedom from the threat of intratracheal fire during these procedures.

Vein Finder

One interesting new device was an ultrasound "finder" for central veins, particularly in the neck. The hand-held instrument gives a remarkably dear picture of the vessels in the neck and has on it a guide for the probing" needle who can almost be seen actually puncturing the vein as it is advanced. This type of device may both reduce accidental carotid and pleural punctures and also speed significantly the process of central line insertion.

Coags at the Drop of a Drop

Another new device was a coagulation monitor that uses only a drop of blood and can measure prothrombin time and activated partial thromboplastin time in a few seconds. Proposed use in the operating room to guide coagulation therapy was cited as a safety enhancement.

QA Systems Shown

In the scientific exhibits, them were three examples of anesthesia quality assurance systems. Each involved computer driven data bases, but the details of data collection, processing, display, and reporting varied widely. There was also an exhibit involving* an approach to the prevention and detection of substance abuse by anesthesia personnel. The patient safety implications of these presentations were clear and direct. The history of and benefits from patient monitoring were the subjects of an elaborate exhibit prepared by Leslie Rendell-Baker, M.D. and colleagues. A "hybrid artificial intelligence technique for recognizing and diagnosing abnormal capnograms was demonstrated. The exhibitors from Denver noted that eventually there may be a processing system that also initiates suggestions for remedial action based on the information generated by the capnogram analysis. Finally, the latest improvements in one of the well-recognized anesthesia simulators (on-screen presentations using a personal computer) were demonstrated.

The 'Next' Pulse Oximeter

The overall theme of the exhibits was refinement and micro-application of existing basic technology. Several equipment manufacturers were overheard to ask, "What is the next revolutionary technology equivalent in impact to the pulse oximeter?" Observers of these conversations concluded that there appeared to be no answer to this question.

Dr. Eichhorn, Harvard Medical School and Beth Israel Hospital, is Editor of the APSF Newsletter.

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Editorial: APSF Comes of Age, Works for Safety

In 1990, its fifth year, the APSF continued to work toward its specific goal of improved anesthesia safety. This is not just our goal, but it must be seen as a responsibility of all health care professionals associated with the field.

Emphasis continued on research and, particularly, education, which includes the Foundation's vigorous quarterly APSF Newsletter Most exciting has been the very significant increase in the number of papers presented on related subjects at the ASA Annual Meeting, exceeding 100 for the second consecutive year. In this issue of the Newsletter, highlights of the 1990 presentations are reviewed. In addition, the three Research Grant recipients and the winners of the Ellison C. Pierce, Jr. Award are announced. Dr. Howard A. Schwid commented, upon receiving this award, "Unfortunately, few grants are awarded to develop educational devices, but the APSF has made a strong commitment to improving anesthesiologists' training through the development of simulators. Benefits of the foundation's support will be realized soon and for years to come!'

Letters to the Editor and opinion pieces on anesthesia safety from all over the country and also around the world continue to multiply, establishing the Newsletter as a vehicle for debate on controversial subjects. Readers have frequently commented on areas of their own specific concern, such as operating room noise and alarms or the problem of inadequate drug labeling, thus stimulating readers to examine their own practices and em consider responding with another letter to the APSF Newsletter

Anesthesia Safer Now

Elsewhere in this issue is a summary of the dramatic (even more than for the physician community at large) recent reductions in anesthesia malpractice insurance premiums. There have been extensive discussions and presentations about the reasons for these premium cuts. We at the APSF believe it an inescapable conclusion that anesthesia care in this country is safer today than it was only a few years ago and, further, we hope that the principles and efforts put forth by the APSF have helped in this improvement in safety.

1990 has been particularly important for a significant increase in corporate contributions to the Foundation. Mr. Clifford Parish of Burroughs Wellcome Co. is Chairman of the Committee on Development and has been ably assisted by Mr. G. Douglas Wicker, who was appointed Director of Development for the APSF "year Volunteer ASA membership exceeded 4,000 anesthesiologist during the year. In October, the ASA House of Delegates approved a dues increase for ASA members that will include as one of its three components an eventual contribution of $400,000 in 1991 to the Foundation and consequent automatic APSF membership for all ASA members. A significant portion of the ASA monies will be placed in an APSF endowment fund.

In the coming year a major educational effort will be a planned conference on Human Error in Anesthesia, scheduled to occur in February, 1991, in collaboration with the Food and Drug Administration. Thirteen of the world's leading experts in human factors and human performance in areas such as aviation, heavy industry, nuclear power, and the military have accepted the invitation to meet with a group of anesthesia research and clinical leaders experienced in the area, to teach and then apply the Knowledge of other disciplines to the special problems of anesthesia.

Other educational endeavors will include considerable further support in the development of simulators for training in anesthesia crisis management.

Lastly, in order to allow continued growth of the already-strong APSF efforts, I urge corporate donors, CRNA'S, and any other interested parties to increase their contributions to this Foundation in 1991. AU of us on the Board of Directors genuinely welcome suggestions and comments from the membership at all times. Let us hear from you and let us continue to work together towards even safer anesthesia cam

Ellison C. Pierce, Jr., M.D. President, APSF

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APSF Awards Three Research Grants at Annual Meeting

by Jeffrey B. Cooper, Ph.D.

The APSF Committee on Scientific Evaluation this year reviewed twenty-five applications and awarded research grants totaling $105,000 to the top three proposals.

'Smart' Alarm to be Taught

Dr. Dwayne Westenskow of the Department of Anesthesiology, University of Utah, building upon his group's past experience in developing "smart" alarms for anesthesia monitoring, was funded for a project entitled "Fault Detection and Alarm Generation During Anesthesia Using Neural Network Based Pattern Recognition." New-al network theory is relatively new, but has promise for giving computers human-like performance in speech, image and pattern recognition.

In this work, a neural network will be taught to recognize patterns of change in the patient's physiologic variables as a basis for generating alarms during anesthesia. The specific goal of the project is to train a network to recognize ten different patient related critical events. Training data will be generated using a breathing system/transducer array and the oil/water--r lung model created earlier by this research group. The expectation is that the alarm system will accurately identify 99% of the critical events which may occur during anesthesia.

Data Display Evaluated

Dr. Matthew Weinger of the University of California, San Diego will be studying "The Effect of Mode of Visual Display of Anesthesiologists' Monitoring Performance. He will be collaborating with Dr. Carl Englund, who has extensive research experience in human factors m relationship to cognitive and physical performance. The principal hypothesis to be tested in their experiments is that the way in which clinical data are presented affects the ability of anesthesiologists to analyze and diagnose critical events.

A realistic simulated visa monitoring environment will be created us" actual anesthesia equipment. After controlling for training effects and establishing baseline performance anesthesiologist subjects, the effects on monitoring performance of three different display modes of an Ohmeda CD anesthesia machine will be ascertained. It is reasoned that the results of the project will assist in the improvement of designs of monitoring displays with particular application during stressful or high workload situations.

Difficult Air-way Prediction

Dr. Satwant Samra, of the Department of anesthesiology, University of Texas Medical Branch at Galveston, will be addressing & issue of improving techniques for identifying the patient who will be difficult to intubate. In collaboration with Dr. F.C. Guinto, Professor of Radiology, Dr. Samra will study differences in anatomical de" of the upper airway, using magnetic resonance imaging and soft tissue radiography in surgical patients who present the problem of difficult intubation and compare them to controls who are matched in age and weight. The object is to compare the findings from MRI with those of soft tissue radiographs of the neck. The hypothesis is that patients would first be identified as potentially difficult for intubation according to Samsoon and Young's modification of Mallampatti's grading system. The investigators hope to identify details of soft tissue radiography that would then be useful for improving predictability of which patients would be difficult to intubate.

The research grants program will continue next year with the same deadlines and in the same fashion as previously (see announcement on page 1). One notable exception is that the award limit will be increased to $60,000.

This year, investigators whose applications were not selected for the second round of reviews were informed very quickly a mere eight weeks after the deadline for receipt of applications. During that period all 25 applications were reviewed by each member of the Committee The top sewn were considered in the second round of reviews and the final decision was made at the meeting of the Committee-, which was held as usual on the first day of refresher courses at the Annual Meeting of the American Society of Anesthesiologists. Following that meeting, a summary of the reviewers' comments was sent to each principal investigator who had requested it.

The set of grant applications as in previous years, represents a broad range of ideas that the investigators connect with anesthesia patient safety. Many of the applications represent new ways of looking at existing problems or definitions of new areas that deserve attention. Unfortunately, many applications suffered from the same problems described in the APSF Grant Program Report last year (see APSF Newsletter Volume 4, No. 4, December, 1989). New investigators are encouraged to read that report to get a better idea of the types of topics that have been funded in the past and the kinds of flaws that have prevented applications from being approved.

Dr. Jeffrey B. Cooper is the Chairman of the APSF Committee on Scientific Evaluation. Reports of last year's detailed report, which includes information on what grants have been funded and suggestions for creating a successful application can be obtained directly from him at the Department of Anesthesia, Massachusetts General Hospital, Boston, Massachusetts 02114.

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Ellison C. Pierce, Jr. Award Winner Announced for 1990

Winners of the Ellison C, Pierce, Jr. Award for 1990 were Howard A. Schwid, M.D. (right) and Daniel O'Donnell, Ph.D. who are shown at the ASA Annual Meeting standing in their scientific exhibit of an on-screen computerized anesthesia simulator.

The Anesthesia Patient Safety Foundation announced, at the conclusion of the ASA Annual Meeting the selection of Howard A. Schwid, M.D. and Daniel O'Donnell, Ph.D., from the Department of Anesthesiology, University of Washington, Sea* as the recipients of the Ellison C. Pierce, Jr. Award for 1990.

The award was made for their scientific exhibit entitled "The Anesthesia Simulator Consultant: Simulation Plus Expert System." The award consists of a $500 prize to the authors and a Certificate of Recognition to the

sponsoring institution.

The award is presented periodically to the exhibitor and sponsor of the scientific exhibit at the ASA Annual Meeting that best demonstrate-s new and effective methods of safe anesthesia practices.

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Anesthesiologists' Claims, Insurance Premiums Reduced: Improved Safety Cited

by S. Diane Turpin

Many medical malpractice insurance carriers in various parts of the United States have reduced insurance premiums specifically for anesthesia providers. Such cuts follow recognition of decreased pay-out for anesthesia claims. These reductions come on top of the generalized across-the-board premium decreases for all medical personnel in some locations (which have been feature-ed in the Wall Street Journal, The New York Times, Forbes, etc. each with specific mention of anesthesiology as a leader in this area).

Some medical malpractice insurance carriers are agreeing to provide premium discounts for anesthesiologists who adhere to the ASA Standards for Basic Intra-Operative Monitoring and, in so doing, use pulse oximetry and capnography. In Massachusetts, anesthesiologists became the first specialty group in the nation approved by a state insurance division to enter into an agreement with a state-controlled --facility That agreement)specified the patient monitoring standards to be used by anesthesiologists.

In other states, insurance carriers view such patient safety/risk/management efforts as purely voluntary, and provide premium discounts to encourage anesthesiologists to use such measures. Some carriers have developed their own risk management courses and offer anesthesiologists premium discounts for participation. While this presentation in no way provides a comprehensive report of all risk management efforts and rate reductions, it highlights a sample of approaches being taken in some states:


The trailblazing activity in Massachusetts is well known, but is worth summarizing again as part of the national picture In 1997, the Massachusetts Insurance Commissioner approved an agreement between the Medical Malpractice joint Underwriting Association of Massachusetts (JUA) and the Massachusetts Society of Anesthesiologists in which anesthesiologists would pulse oximetry and -capnography where appropriate, and would always follow the ASA Standards for Basic Intra-Operative Monitoring. In return, anesthesiologists would receive premium discounts of 15 percent for claims made policies and 20 percent for occurrence policies. At the time of the agreement, the premium relativity for anesthesiologists was 5.0 (this is the actuary determined risk of a specialty practice compared to & lowest risk group). While several specialty groups applied for rate relief based on risk management activities, only anesthesiology was accepted as a suitable test group.

Anesthesiologists who adhered to the JUA Standards on July 1, 1988 were rated down from a relativity of 5 ($24,268) to a relativity of 4 ($20,210), minus the 20 percent for occurrence policies and 17.S percent for claims made policies. On July 1, 1989, anesthesiologists who followed the JUA Standards were rated down to a relativity of 3.5, ($20,088) minus the 20 percent for occurrence and claims made policies. Beginning July 1, 1990, anesthesiologists who followed the JUA standards were rated down to a relativity of 3, ($17,219) minus the 20 percent for occurrence and claims made policies.

In addition to rate reductions for anesthesiologists, a report compiled by the JUA indicates a significant decline in the number of claims for hypoxic injury" The report showed that between 1975 and the beginning of the risk management program in July, 1997, JUA averaged six to eight hypoxic injury claims per year. Although six hypoxic claims were reported between July, 1987 and the end of that year, none of the claims involved anesthesiologists who participated m the risk management program. The anesthesiologists named in the claims did not fully utilize pulse oximetry or capnography. Between January, 1988 and March, 1989 no hypoxic injury claims were reported and only two hypoxic injuries were reported between April, 1989 and February, 1990. Of these, the investigation of the first claim revealed that the hypoxic injury was related to a medical equipment problem, not anesthesia care. The second patient had the benefit of capnography, but not oximetry, and the case remains under investigation.

The medical malpractice insurance rates for policy year beginning July 1, 1991 are expected to reflect a 20-2 5 percent reduction across the board in the base rate for all physicians, plus an additional 20 percent discount for anesthesiologists. Therefore, for the policy year beginning July 1, 1991 the current 1990 rates of $17,219 for a $1/3 million, occurrence policy are expected to be reduced to approximately $12,900 with the rate further reduced by 20 percent ($2,580) for those anesthesiologists participating in the risk management program.


Mutual Insurance in Alabama implemented a risk management program in July, 1990. The Anesthesia Monitoring /Documentation Credit gives a 20 percent premium credit to anesthesiologists who agree to use pulse oximetry and capnography and to document such use. Mutual Insurance figures approximately 90 percent of the anesthesiologists in Alabama who practice outside of the University of Alabama hospital -setting.


The Colorado Physicians Insurance Company has had patient saw guidelines in effect for four years. While the insured are not required to follow the guidelines and & company does not offer discounts to encourage compliance, the company reports that the number of claims against anesthesiologists has declined and as a result the malpractice premiums have been reduced. The decline in claims over the past three years is attributed to the implementation of patient safety guidelines.


In 1990, physicians were offered a 5 percent discount (up to $ 1,000) for participation in the Medical Association of Georgia (MAG) Mutual Insurance Company's voluntary risk management program. The program contains one seminar to address basic risk prevention skills and another seminar targeted to the physicians specialty. Eligible physicians receive a discount for each seminar.


Indiana anesthesiologists were successful in negotiating new contracts with their medical malpractice carriers by showing that they are now subject to fewer and less costly claims. The anesthesiologists were reduced from a Class 5 to a Class 4 risk, a decrease of about $ 6,000 in premiums. The Physicians Insurance Company of Indiana granted a 20 percent discount for anesthesiologists who use pulse oximeters and capnographs.


The Kansas Society of Anesthesiologists worked with the Kansas Medical Mutual Insurance Company (KaMMCO)to achieve a 25 percent rate reduction for anesthesiologists agreeing to abide by the ASA Standards for Basic Intra-Operative Monitoring. KaMMCO Ls a physician-owned insurance company.


LAMMICO, the Louisiana Medical Mutual Insurance company now requires that anesthesiologists use pulse oximeters. In return, anesthesiologists receive a 20 percent discount in premiums and a Class 5 rating. The use of pulse oximeters had been voluntary until this year.

New York

In New York, legislation was passed to provide an "appropriate" reduction in medical malpractice insurance premium for physicians who complete an approved course in risk management. The insurance superintendent has the authority to determine the amount of the reduction and to set the standards for the risk management course


In 1989, the Northwest Physicians Mutual Insurance Company in Oregon provided a I 5 percent reduction to anesthesiologists who agreed to follow practice guidelines similar to those of Massachusetts JUA. In 1990, anesthesiologists were graded down to a Class 4, with a premium reduction of more than 25 percent.


In 1987, the Texas Medical liability Trust (TMLT) initiated a program whereby anesthesiologists who would agree to monitor their patients consistent with ASA Standards would receive a 6 percent reduction in medical malpractice premium. Since 1987, the premium reduction has increased to 25 percent. In addition, TMLT has developed its own risk management course and offers participants a 5 percent premium discount.

TMLT has released a report on the program which states that "'. . the ongoing study of anesthesia claims and their origins at TMLT has shown a significant decrease in the number of claims reported since the implementation of anesthesia patient safety *guidelines:' The report also states that the claims ". . . appear to be of somewhat less severe patient outcomes and fewer hypoxic catastrophes."


The Wisconsin Society of Anesthesiolosists successfully negotiated with the Physician Insurance Company of Wisconsin (PIC-WIS) and received discounts of up to 25 percent for following specific practice guidelines, including the use of oximetry and capnography.

The reports from the Massachusetts and Texas experiences are encouraging both in terms of fewer claims and reduced premium. Abiding by the ASA Standards for Basic Intra-Operative Monitoring and using pulse oximetry and capnography may result in significant savings for anesthesiologists now negotiating new policies.

Ms. Turpin is state Issues Coordinator, ASA Office of Governmental Affairs, Washington, D.C,

Editor's Note: Additional contributions of information about risk management/patient safety efforts in other states or insurance companies are very welcome and will be published here.

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Reporters Ask Safety Questions During ASA 'Media Tour'

by Richard H. Stein, M.D.

Anesthesia patient safety was the main topic of interest to reporters from the print and broadcast media at the American Society of Anesthesiologists' Annual Meeting in Las Vegas in October. Thirty-two representatives of the media, the largest group in the history of the ASA, attended the very well received President's Media Tour. Because of the obvious interest to readers, listeners, and viewers and because of past public education efforts of the ASA, many of the questioners gathering information or conducting interviews inquired about the safety of the anesthetic experience

Outgoing ASA President Richard Stein, M.D. appeared on the local ABC-TV and CBS-TV affiliates. There were two major newspaper stories, in the L-is Vegas Sun and the Reno Gazette journal. Dr. Stein was also interviewed on radio by the local CBS station and had a 20-minute interview with the News Director of the National Public Radio station serving the area. Also, Dr. Stein appeared for one hour on the "Las Vegas Profile" radio program and gave a 30-minute live studio call-in interview on the "People Talk" show. AU these activities illustrate the breadth and depth of the media and public interest in the practice of anesthesiology, particularly the saw aspects.

The main theme and principle concern of the reporters was, "Why is it safer today to receive an anesthetic ever before?" Three main reasons were offered as the fire level of response to these questions. First, there is the routine use of the pulse oximeter, providing continuous monitoring of hemoglobin saturation and thus giving the anesthesiologist very early warning signs of declining blood oxygen. Prior to 1 9 84, estimated risk of anesthesia-related deaths was I in 10,000. These may be excellent odds if you are in Las Vegas, but are totally unacceptable if that one person was a member of your family or your patient. The safety and well-being of our patients is the anesthesiologists' chief concern. Also with the principles outlined in the ASA Monitoring Standards, having pulse oximetry routinely and with the addition of the routine use of capnography during general endotracheal anesthesia, the risk of anesthesia caused death has fallen to at least I in 30,000 and probably much lower. This is a dramatic drop in presentable complications and we now see concomitant relief in the significant cuts in malpractice premiums for anesthesiologists.

The second reason why it is safe-r to receive an anesthetic today is our newer anesthetic agents, e.,$ the most recent inhalation agents, beta blockers, short acting muscle relaxants, and intravenous infusion anesthetics. Our knowledge of the pharmacokinetics and pharmacodynamics of our new agents and safer techniques with improved delivery system allows us to safely administer anesthetics to a much wider range of risks among our anesthetic patients. Our modem anesthesia machines with built-in safety features and alarms are helping to decrease preventable equipment related and judgment-related mishaps.

The third, and probably the strongest reason for increased patient safety is the high caliber of the anesthesiologist delivering care. We truly have the brightest and best of young physicians being graduated from our residency programs. Further, our practicing anesthesiologists are dedicated to continuing education to stay current in their knowledge and skills and thus become better clinicians. The modem anesthesiologist is the key ingredient in recognizing the monitors' early warnings and generating the proper timely response with our newer agents and techniques. Anesthesiolosists have proven to be the leaders and pioneers in medical practice quality assurance and peer review.

Several reporters inquired about our ASA Standards and their role in improved cam Thanks to the APSF ,Greater and all the publicity the Standards attracted, we are now seeing publicized the benefits of safer anesthetic administration: fewer catastrophies associated with anesthesia. The practicing clinician is better off today because of the educational efforts of the Anesthesia Patient Safety Foundation. It is only proper that our ASA House of Delegates placed APSF formally within our Society's Dues Structure, guaranteeing support from our entire membership.

ASA Standards Cited

Questions were asked concerning a key issue in patient safety, the fear of not waking up, and even regarding "How does a patient successfully sue you.?" The responses always reflected the positive advances we are making in patient safety and the fact that patients are in excellent hands when being put to sleep by an anesthesiologist.

Four new noninvasive cardiovascular techniques were presented at the Las Vegas ASA Annual Meeting. Automated ST segment analysis uses a computer that continuously watches the electrocardioscope for signs of inadequate circulation to a patient's heart. New noninvasive techniques to monitor continuously blood pressure wave forms will supplement the intermittent blood pressure monitoring technique currently used. Thoracic electrical bioimpedance monitors reveal changes in the electrical conductivity of the chest and thus estimate the quantity of blood being pumped from the heart, providing an early warning of the decrease in cardiac output that may precede changes in blood pressure. Finally, transesophageal Doppler echocardiography using high-frequency sound to evaluate the fine details of cardiac function can provide the earliest possible warning signs of intraoperative myocardial ischemia. All these new techniques are advances that will help improve safety for the patient receiving anesthesia.

Dr. Stein, Vincennes, N, is ASA Immediate Past President.

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ASA Closed Claims Study Tallies 8 Publications

Editor's Note: As of November, 1990, the American Society of Anesthesiologists Closed Claim Project generated eight publications, several of which have implications for anesthesia patient safety. Presented here is a listing of the papers provided by Frederick W Cheney, M.D., Chairman of the ASA Committee on Professional Liability.

1. Caplan, R.A., Ward, R.J., Posner K., Cheney F.W.: Unexpected cardiac arrest during spinal anesthesia: a closed claims analysis of predisposing factors. Anesthesiology 68:5-11, 1988.

This is an in-depth review 14 cases of unexpected cardiac arrest in healthy patients winch were identified in the first 900 claims reviewed in the ASA Closed Claims Project. A major factor in the poor outcome (six deaths, eight permanent brain damage) seem to be inadequate appreciation of the need for early treatment of cardiac arrests with alpha agonists in order to counteract sympathetic blockade.

2. Caplan, R.A., Posner, K., Ward, R. J., Cheney, F.W: Peer reviewer agreement for major anesthetic mishaps. Quality Review Bulletin 14:363-368, 1988.

A study of the reliability of dosed claims reviewer judgments about standard of care, presence or absence of human error, and the role of better monitoring in the prevention of anesthetic mishaps.

Forty-two anesthesiologists reviewed 48 closed claims abstracts of anesthetic mishaps. The data demonstrated that anesthesiologists from widely different backgrounds can produce a cohesive set of judgments about anesthetic mishaps.

3. Cheney, E W, Posner, K., Caplan, R. A., Ward, R. J.: Standard of care and anesthesia liability. 1. Amer. Med. Assoc. 261:1599-1603, 1989.

The ASA Closed Claim database of 1,004 lawsuits was examined to define the impact of the "Standard of Care" as judged by practicing anesthesiologists on the likelihood on an amount of financial recovery. This paper provides a general overview of the methodology of the project. The most important finding was that if the anesthesiologist provides appropriate care there is still a greater than 40% chance that payment will be made for a claim of malpractice.

4. Tinker, J. H., Dull, D. L., Caplan, R. A., Ward, R. Cheney, E W: Role of monitoring devices in prevention of anesthetic mishaps: a closed claims analysis. Anesthesiology 71:541-546, 1989.

A review of 1, 175 closed claims indicated that about one-third or the negative outcomes could have been prevented by application of additional monitors. The adverse outcomes judged preventable by additional monitoring (end tidal C02 and pulse oximetry) are eleven times mom costly than those mishaps not judged preventable

5. Caplan, R. A., Posner, K. L., Ward, R.J., Cheney, R.W: Adverse respiratory events in anesthesia: a closed claims analysis. Anesthesiology 72:828-833, 1990.

A review of 1,541 cases from the ASA Closed Claims" database showed that three mechanisms of injury accounted for three-fourths of the adverse respiratory events: inadequate ventilation (196 claims; 3 8%), esophageal incubation (94 claims; 18%), and difficult tracheal intubation (87 claims; 17%). The esophageal incubation group was notable in that in 48% of the cases where auscultation of breath sounds were performed and documented, this test led to the erroneous conclusion that the endotracheal tube was correctly located in the trachea.

6. Kroll, D.A., Caplan, R. A., Posner, K., Ward, R.J., Cheney, F. W: Now injury associated with anesthesia. Anesthesiology 73:202-207, 1990.

Of 1,541 claims reviewed, 227 (15%) were for anesthesia related nerve injury. Ulnar neuropathy represented one-third of all nerve injuries and was the most frequent nerve injury. Less frequent sites of injury were brachial plexus(23%)and the lumbosacral nerve roots (16%). Nerve damage is a significant source of anesthesia related claims but the exact mechanism of the injury is often unclear.

7. Posner K.L., Sampson, P.D., Caplan, R.A., Ward, R.J., Cheney, F W: Measuring interrater reliability among multiple raters: an example of methods for nominal data. Statistics in Medicine 9:1103-1115, 1990.

This paper describes some of the statistical refinements utilized to measure interrater reliability in the ASA Closed Claims Project.

8. Chadwick, H.S., Posner, K., Caplan, R. A., Ward, R.J., Cheney, E W: A comparison of obstetric and non-obstetric anesthesia malpractice claims. Anesthesiology. (in Press)

This is a review of 190 obstetric anesthesia claims which represent 12% of the overall 1,541 ASA Closed Claims Project Database. The most common OB claims were maternal death (22% of all OB claims), newborn brain damage (20%), and headache (12%). The group of OB claims contained a proportionally greater number of minor injuries such as headache, backache, pain during anesthesia and emotional injury (32%) compared to the non-06 claims (4%).

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Anesthesia Techs Form National Society

Safety One of Many Benefits

by Dennis McMahon

In conjunction with the annual meeting of the ASA, the American Association of Anesthesia Technologists and Technicians (ASATT) held its first annual meeting in Las Vegas, on October 21.

The ASATT was formed in late 1989 as an educational organization whose goal is the improvement and eventual standardization of the training and skills of anesthesia technical personnel i.e. those who support, but do not perform, anesthesia patient care. It is intended to serve as a nationwide network for individual technicians, as well as for the state and regional societies of anesthesia technologists that have formed within the past six years. Currently there are active societies in New England, New York, Ohio, Colorado, California, and the Northwest and them is interest in other regions.

Bylaws for the society were written, submitted, and ratified by the membership earlier this year. The society is governed by a Board of Directors representing each of seven regions of the country and four elected officers. At the morning session of the Las Vegas meeting, committees were formed to manage membership, meetings, elections, bylaws, certification, training, and publications. The afternoon session included technical presentations from anesthesia machine manufacturers, as well as a session on forming a technician society.

The principal focus of the leadership this coming year will be to increase membership and promote communication within the national population of anesthesia technicians. These goals will be met through the publication of a quarterly newsletter, beginning in January. The newsletter will provide reviews of current technology and new equipment, abstracts of problems with specific devices, announcements of meetings or seminars on anesthesia technology, and reports on progress toward the standardization of preparation and role of technical personnel.

Both patient safety and efficiency are enhanced by knowledgeable support personnel. Well-trained technicians who understand the principles and rationale for the technology that they deal with wig provide an additional line of defense against critical incidents caused by machines, monitors, or accessories that are out of tolerance, malfunctioning, damaged, or being improperly applied. Besides the traditional turnover of O.R.'s between cases, proficient support personnel can expedite the logistics of patient care by setting-up equipment and supplies before procedures, as well as assisting with specific intra-operative functions.

To insure continuity of patient care within the anesthesia community, liaison with the ASA and other organizations was also discussed at the ASATT meeting. At the meeting of the ASA's House of Delegates in Las Vegas, a recommendation was approved from the Committee on the Anesthesia Care Team, chaired by I. Cary Andrews, M.D., recognizing the establishment of the ASATT.

Anesthesia clinicians who would like to foster education among their technical support staff are encouraged to contact the


P. 0. Box 22492

San Francisco, CA 94122.

Dennis McMahon, Virginia Mason Clinic, Seattle, is president of the ASATT.

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APSF Survey Reveals Long Work Hours in Anesthesia

60% of Respondents Admit Fatigue Caused Errors

by J. S. Gravenstein, M.D.

In the summer of 1988, a questionnaire was distributed to the recipients of this APSF Newsletter of the Anesthesia Patient Safety Foundation. In it, we encouraged anesthesiologists and nurse anesthetists to 0 us their personal opinion about their hours of work and rest.

Some of the questions (and average responses in hours) were:

1 . After how many continuous hours of administering anesthesia do you need a break? (About 4.7)

2 . Assuming you were able to take brief rest periods or breaks, for how many hours per day can you safely administer anesthesia? (13.5)

3 . During the past six months what is the longest continuous period that you have personally administered anesthesia without a break? (7.2)

4. During the past six months what is the longest with or without breaks that you have personally administered anesthesia? (15.3)

Even though we received almost 3,000 replies this constitutes only about 6.5% of all anesthesiologists, residents, and nurse anesthetists in the United States. The data, therefore, need to be interpreted with this in mind.

Nevertheless, there are those among us who work longer than they themselves consider safe and some 60% of the respondents reported that they had committed an error in anesthetic administration that they attributed to fatigue. This raises & question whether or not the work and rest cycles in anesthesia practice should be regulated, as is the case with commercial airline pilots, truck drivers, maritime personnel, and railroad crews.

Intuitive Rules

Interestingly enough, we could not find scientific studies demonstrating that fatigue has been responsible for accidents and disasters that had happened in these professions nor data that would justify the work-hour limits chosen by the regulators. The rules governing pilots, truck drivers, etc. were devised because it seemed to be intuitively and eminently reasonable that overwork, a lack of rest, and resulting fatigue night lead to the commission of errors and, thus, cause accidents and disasters. Well known are the rules promulgated by the state of New York that govern the work-rest patterns of house staff and emergency room physicians. However, no scientific data exist with which to support the New York or other specific regulations affecting the work/rest cycles of medical personnel.

An Ancient Tradition

In medicine, the tradition of working long hours dates back to medieval times when both male and female members of religious orders provided care to the sick and debilitated. In modern medicine, the concern for the continuity of care and the anesthesia provider-to-patient relationship make it inadvisable to establish rigid rules on work hours; yet, practitioners should examine their practice patterns and determine whether they work longer than they themselves consider safe (as in our sample almost 75% had indicated).

We must also recognize that excessive working hours may interfere with family fife, education, and with the satisfaction that we and our colleagues derive from our practice.

Role of Rhythms?

In arriving at reasonable recommendations for work and rest cycles, many factors need to be considered. Tolerance for extended work may differ greatly among individuals. There is some evidence that after 18 hours, and particularly after 24 and 36 hours, the performance of workers begins to decrease. Also, circadian rhythms affect our performance, especially with periodic decreases in activity and alertness, particularly between 4:00 a.m. and 6:00 a.m. for people on regular day-shifts schedules. We may also be affected by our personal health, by the emotional freight we bring along from our families and homes, the atmosphere in & operating room, and by our relative experience.

The report "Work and Rest Cycles in Anesthesia Practice", sponsored by the Anesthesia Patient Safety Foundation, was published in Anesthesiology 1990; 27:737-742.

Dr. Gravenstein, University of Florida College of Medicine, Gainesville, is a member of the APSF Executive Committee.

Editor's Note: This brief summary of responses to the questionnaire reveals some astounding information. Even considering the possibility that the respondents were partially self-selected because they work very long hours, note that the longest continuous period for administering anesthesia without a break averaged 72 hours (suggesting there were many periods considerably longer than that). Similar concern can be expressed about the 15.3 hour average for the longest period of administering anesthesia. Are there safety implications of these remarkably extended working hours in the OR? Reader comments are invited.

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Letter to the Editor

November Letter from Persian Gulf Anesthetists Tells Working Conditions, Anesthesia Monitors

To the Editor:

The anesthesia team here in Baharan, Saudi Arabia has done over 130 cases so far. Patient monitoring consists of manual blood pressure precordial stethoscope, pulse oximetry, and lots of dose observation, both perioperatively and in the PACU. We live in tents, operate in "MVST" units which are powered by noisy U-Packs. We are fortunate enough to now have a liquid oxygen supply source Our patients have done well and, of course, come from a young healthy population. Our drug supplies seem to have sustained their potency in spite of the extreme temperature We are anticipating a large shipment of automated non-invasive blood pressure devices to overcome operating room noise. We endeavor to maintain the safest possible environment and utmost vigilance during the anesthesia care of our patients.

Just thought you might like to know.

Stephen I. Sherer, LTC, RNC Chief Nurse Anesthetist Operation Desert Shield

28th Combat Support Hospital

ETT Ventilation Problem Protocol Challenged

To the Editor:

In a Letter to the Editor appearing in the Fall 1990 APSF Newsletter (1), Drs. Kataria and Nicodemus offer readers a response algorithm for dealing with the emergency of difficulty in ventilating a patient via endotracheal tube (EM following apparent intubation of the trachea. They are to be commended for their effort to formulate a simple, systematic approach to a potential catastrophe. However, conspicuously (and inexplicably) absent from their protocol is a branch point which stresses the urgent need to ensure adequate oxygenation and ventilation of the patient by some means other than the recently placed ETT.

The main branch of the algorithm begins with the determination that the difficulty in ventilating via the M is due to a problem on the patient side of the breathing system, and proceeds through a series of steps which include reauscultatation, repeat laryngoscopy, passage of a suction catheter via ETT, and even chest x-ray and fiberoptic bronchoscopy to confirm proper placement of the ETT in the trachea. If followed to its conclusion in the setting of difficulty or inability to ventilate via ETT, such a protocol would virtually guarantee significant hypoxemia in an anesthetized, apneic patient, even if preoxygenation had been employed.

As competent and caring practitioners, most anesthesiologists and anesthetists might react to this criticism by exclaiming "Well, of course, we wouldn't take this sequence literally; we would ensure that the patient is oxygenated!" as, I am sure, would the authors of the protocol. The very nature of our training and clinical thinking rests on the foundation of providing for adequate oxygen delivery to the vital organs of any patient under our care. However, performing this vital task in the circumstance whereby an ETT is malfunctioning necessarily requires removal of the ETT and resumption of controlled ventilation via facemask, assuming the latter had preceded laryngoscopy and had not been diffucult. This, of course, violates the prescribed sequence of steps in the algorithm, thus negating its utility and validity.

A clinical response algorithm has been defined as "a logical sequence of [steps] to be [followed] in response to a specific condition [as a] guide… in performing maneuvers of maximal diagnostic merit in the least amount of time" (2) Such stereotyped responses to clinical problems have occasionally been criticized because of their apparent promotion of an unthinking "cookbook" approach to problem-solving. (3, 4)

Although, by definition, an algorithm indeed precludes a knowledgeable interpretation of data and reliance on considered judgement, it is intended to service as a surrogate for the latter. As such, it is valid only in a clinical circumstance exhibiting such a degree of emergency that, with time at a premium and stress at a peak, judgment might reasonably be expected to be clouded and responses should occur by rote. A valid algorithm must therefore dearly prescribe the proper application of fundamental principles without containing any unspecified presuppositions. If it does not, then it is, at best, redundant and, at worst, dangerous.

The protocol suggested by Drs. Kataria and Nicademus for dealing with unanticipated difficulty in ventilating a patient following endotracheal intubation, an emergency which they themselves describe as one which "can lead to patient mortality or morbidity if not handled in a timely and intelligent manner [emphasis mine]," (1) falls short by omitting an early step for otherwise ensuring adequacy of oxygenation and ventilation. Assuming the patient had not been difficult to ventilate by mask prior laryngoscopy, such a step would likely be to remove the ETT and resume ventilation with 100% oxygen via facemask. In the much less likely but far more dangerous situation in which neither ventilation by M nor mask is possible, detailed response guidelines have been offered elsewhere. (5)

Robert E Atkins, M.D.

Abington (PA) Memorial Hospital; Assistant Professor of Anesthesia

Temple University School of Medicine


1. Kataria B, Nicodemus R. Protocol suggested for ventilation problem following intubation (letter). APSF Newsletter 1990; Vol. 5, No. 3, p. 30.

2. Raphael DT, Weller RS, Doran DJ. A response algorithm for the low-pressure alarm condition. Anesth Analg 1988; 67:876-83.

3. Standards and guidelines for cardiopulmonary resuscitation (CPR) and emergency cardiac care (ECC). JAMA 1986; 255:2905-2932.

4. Narins RG, Cohn JJ. Bicarbonate therapy for organic acidosis: the case for its continued us (editorial). Ann Int Med 1987; 106: 615-8.

5. Benumof JL, Scheller, MS. The importance of transtracheal jet ventilation in the management of the difficult airway. Anesthesiology 1989; 71:769-78.

Passage of Suction Catheter Via ETT Cited as Possibly Misleading, Waste of Time

To the Editor:

I have read with interest the recent protocol suggested

by Drs. Kataria and Nicodemus for ventilatory difficulty subsequent to intubation. In the Fall 1990 issue of the Newsletter. It calls for passing a suction catheter through the endotracheal tube following direct laryngoscopy.

This procedure may not detect a significant problem in the endotracheal tube and why waste valuable time I and others haw noted on occasion the ease with which a suction catheter may be passed through a large, tenacious mucus plug in an endotracheal tube. The ability to pass a catheter with apparent ease does not insure a patent endotracheal tube.

Perhaps the protocol would more appropriately state:

3. Release endotracheal tube cuff and manipulate endotracheal tube: rule out herniation of cuff, kinked, compressed, bevel of endotracheal tube against tracheal wall. If difficulty continues, change endotracheal tube.

One must not allow the possibility of profound anesthetic morbidity or mortality to result from a catheter patent but functionally blocked endotracheal tube.

Jonathan D. Lamb, M.D., FRCP(C)

Clinical Assistant

Professor of Anesthesia

Saskatoon, Saskatchewan, Canada

ETT Removal, Use of Mask Recommended for Protocol

To the Editor:

Perhaps one day you will quit sending me the APSF Newsletter because of my persistence. In spite of this, I write, about a letter to the Editor which appears in the Fall 1990 issue on Page 30. I preface further comments with the realization that a Letter to the Editor is by definition information from the outside. I am aware that this is not a letter from the Editor.

Drs. Kataria and Nicodemus provide a protocol and algorithm or at least a protocol as to what one does when confronted with lungs which are difficult to inflate following intubation. If I may assume they are discussing a situation in which ventilation was not difficult prior to intubation, I believe they neglect what has served many of us well as a basic principle over the past several years. No where do these doctors mention that if ventilation were not difficult before the tube was inserted and was difficult after the tube was inserted, one of the wry early things which should be done is to remove the tube and reestablish ventilation by mask. It seems wise to me that this be done before such time consuming things as chest x-ray and, in most institutions, fiberoptic bronchoscopy are attempted

Unfortunately I have no absolute data, but it is a clinical impression for many of my colleagues and me that this has prevented much hypoxia and other sequelae of inadequate ventilation by connecting the problem quickly and allowing further assessment to be done in an atmosphere of adequate ventilation.

William K. Hamilton, M.D.

Vice Dean, University of California, San Francisco

PACU Oximeters Criticized

To the Editor:

I am responding to a recent APSF Newsletter (Volume 5, Number 3, Fall 1990, pgs. 25 and 27) relating to proposed standards for basic monitoring in the PACU. I have never been in favor of pulse oximetry as a standard of care. While it is very useful in certain situations, I find its use being mandated routinely by the ASA is unfortunate. The unfortunate aspects of this are: 1) it contributes to camouflaging of the bad anesthesiologist's or anesthesia caregiver's incompetence and 2) it propagates incompetence by making trainees monitor-dependent as opposed to honing their clinical acumen/skills.

As astutely noted in a recent excellent editorial by Dr. Arthur Keats entitled "Anesthesia Mortality in Perspective" (Anesthesia and Analgesia 71:113, 1990): "pulse oximetry was made a part of our monitoring standards without demonstration of its efficacy." In addition, "making a monitor part of the standard of care guarantees that the experiments necessary to document its efficacy can never be carried out because we automatically rule out a control group." Now your committee and your newsletter are trying to mandate pulse oximetry as a standard of care in the recovery room environment. You state that "closed claims studies indicate that hypoxic injuries in the PACU continue to occur and in fact may be increasing." Again, as Dr. Keats so astutely points out, some of the closed claim data is now being called into question by Dr. Cheney, the investigator who has been responsible for the study over these recent years.

The presence of an instrument such as the pulse oximeter encouraw users who do not understand its technology to be even less vigilant in physical observation of the patient than they were before its use. In other words, it takes the caregiver farther away from the patient because "the little red number is okay."

Another important aspect of this is the impact of such a decree on medical economics. We have a hard enough time in our hospitals getting state-of-the-art equipment to administer safe anesthesia in the operating room. We will probably have an equally difficult time in our PACU to find the resources to purchase state-of-the-art monitoring equipment for this area. With a 15-bed recovery room, if we were to suddenly, as of January 1, 1992, be required to purchase pulse oximeters for all stations, that would represent a cash outlay, perhaps, of $75,000 - 100,000. Failing that, we would then be in violation of standards. You can rest assured that if such equipment is purchased, not only in our hospital but in every other hospital in this country, the cost of the use of that device will be passed on to the consumer or patient. Up goes the cost of medical care again, which is already too high in this country.

If I may at this point refer you to yet another astute publication of Dr. Keats' (the Rovenstein Lecture, Cardiovascular Anesthesia, Perceptions and Perspectives. Anesthesiology 64:67, 1984) he noted how "the pendulum swings in patient cam practices over the years." With that thought in mind, if I could be permitted to gaze through a crystal hall for a few seconds, I would submit to you that the time will come when the results show that all of this fancy technology does not help one bit if you have a careless and/or unskilled operator at the helm. In the meantime, making the use of this equipment mandatory when it has not been scientifically validly proven that it is beneficial, will have cost the medical care system in this country millions of dollars. Is there no room for nurse and physician judgment in patient care any longer of will we all have to become robots who can only function with assistance from machines?

I would ask that you and your committee and others who think along these type of lines would give this problem serious consideration. I do not think what you are about to do is wise or beneficial.

Lawrence L. Priano, M.D., Ph.D.

Associate Professor of Anesthesiology

Oregon Health Sciences University, Portland

Editor's Note: The favorable action of the ASA House of Delegates on the PACU monitoring proposal will be covered in the Spring issue. Comments on the interaction of safety-promoting technology with "careless and/or unskilled" anesthesia providers are enthusiastically anticipated and will be published in future issues.

OB Personnel Standard Raises Questions

To the Editor:

A problem has arisen at our facility which may be common to other facilities and which might be best answered by members of the Anesthesia Patient Safety Foundation or other readers of the Newsletter

We have recently instituted an epidural program for laboring parturients. As in many settings, our program rapidly evolved from the use of intermittent bolus techniques to that of continuous infusions. While we have a diverse group of anesthesiologists, we are all basically following a similar protocol (dilute bupivicaine plus fentanyl mixture) and we have a standard set of orders drawn up for the obstetrical nurses and CRNAs to follow while the block is operative. We have found the success of the epidurals has been very high with no significant morbidity.

Recently, them have been questions posed by some of our anesthesiologists regarding the need for attendance in the facility by the physician after the block has been established and the patient has been monitored for a period of time to rule out untoward events or lack of success of the block. Since there is an in-house CRNA available at all times who is trained to handle any acute emergencies, it did appear that it might be a reasonable approach, especially at night when there are no other cases going on. Further, since we are only billing and being compensated for actual time in attendance with the patient, there would be considerable uncompensated time spent at & facility.

Our program was initiated using the ASA "Standards for Conduction Anesthesia in Obstetrics" as a basis. Unfortunately, Standard VIII specifically states that a physician shall remain in the facility until the patient is accepted in a recovery phase unit. This, in effect, proscribes the physician from leaving the facility. Yet, members of my Department say they are aware that this is not the case in many other facilities. Further, with this Standard in black and white, the hospital administration indicates that this poses an unacceptable liability risk to the facility, as well as to the physicians, and they will not allow us to leave in these situations.

My questions, therefore are. (1) With the general utilization of infusion techniques, is there any change contemplated in the stated Standard, or should there be any reason to change this Standard? (2) If my colleagues are correct that many other institutions are handling this differently, how can these facilities be practicing in accordance with ASA Standard VIII, as currently promulgated? (3) Again, if my colleagues are correct, is there, in effect, a new de facto Standard which might be replacing the existing standard? (4) If we must remain in the facility, is there any justification in seeking some monetary compensation from the Health Center for providing the availability of this service, and, is such a thing being done elsewhere? I don't think it would be possible or reasonable to bill the patients any more than a "base" plus actual time in attendance. It would make the service prohibitively expensive to patients.) (5) Are there alternative methods which are in accordance with the existing Standards?

I would be interested in any responses to these questions.

Mark H. Zeitlin, M.D., Chairman Department of Anesthesiology Saint Vincent Health Center Erie, PA

Editor's Note: It is this type of question and many other related questions that led to an intense review of the ASA Standards for Conduction Anesthesia in Obstetrics during 1990. Proposals for modification from the ASA Committee on Standards of Care and Obstetric Anesthesia could not he reconciled in time for approval at the October ASA Annual Meeting. Accordingly, the ASA House of Delegates eventually voted to change the existing obstetric anesthesia "Standards" to "Guidelines" for 1991 with the expectation that there will be a new proposal to consider in October, 1991. Therefore, now is the perfect time for Dr. Zeitlin and all other interested practitioners to address comments such as the above to the ASA for referral to both involved committees.

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Symposium for Operating Room Team to Be Held in May

The American College of Surgeons' Committee on Operating Room Environment in cooperation with the Association of Operating Room Nurses and the American Society of Anesthesiologists is sponsoring Symposium VU on Operating Room Environment.

The Symposium will be held in Orlando, May 6-8, 199 1, at the Peabody Hotel. It features a format designed to improve dialogue among surgeons, nurses, and anesthesiologists in the operating room. Participants must register as a team representing their hospitals. No individuals are accepted. The win may be two persons (surgeon and nurse) or three persons (surgeon, nurse and anesthesiologist).

Four panels will cover the following topics:

AIDS and Other Infectious Risks in the Operating Room

Ambulatory Surgery: Making It Effective, Efficient and Safe

Computerization of the Operating Room: Like It or Not

Turf Battles: Who is the Assistant in the Operatin Room (Tech, RN, PA, or M.D.)?

Panels will be followed by small group workshops where questions will be formulated to be discussed by the panelists in general session.

Anesthesiologists serving as panelists are

Arnold J. Berry, M.D., Atlanta (AIDS)

Jeffrey Apfelbaum, M.D., Chicago (Ambulatory surgery)

David Paulus, M.D., Gainesville (Computerization)

Marcelle Willcock, M.D. of Boston will moderate the panel on computerization. John E. Plumlee of Lexington, KY is ASA Liaison to the Committee on Operating Room Environment.

For more information on this Symposium and to obtain registration material contact: Mr. Jeffrey Knezovich, Organization Department, American College of Surgeons, 55 East Erie Street, Chicago, IL 60611-2797,(312) 664-4050.

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The Anesthesia Patient Safety Foundation Newsletter is the official publication of the nonprofit Anesthesia Patient Safety Foundation and is published quarterly in March, June, September, and December at Overland Park, Kansas. Annual membership: Individual $25,00, Corporate $500.00. This and any additional contributions to the Foundation are tax deductible. @Copyright, Anesthesia Patent Safety Foundation, 1988.

The opinions expressed in this newsletter are not necessarily those of the Anesthesia Patient Safety Foundation or its members or board of directors. Validity of opinions presented, drug dosages, accuracy and completeness of content are not guaranteed by the APSF.

APSF Executive Committee: Ellison C. Pierce, Jr., M.D., President; W. Dekle Rountree Jr., Vice-President; E.S. Siker, M.D., Secretary; Burton A. Dole, Jr., Treasurer; Jeffrey B. Cooper, Ph.D.; Joachim S. Gavenstein, M.D.; James E Holzer, J.D.

Newsletter Editorial Board: John H. Eichhorn, M.D., Stanley J. Aukburg, M.D., Jeffrey M. Beutler, C.R.N.A., M.S., Ralph A. Epstein, M.D., David E. Lees, M.D., Bernard V. Wetchler, M.D., Mr. Mark D. Wood

Address all general, membership, and subscription correspondence to:

Administrator Anesthesia Patient Safety Foundation

515 Busse Highway

Park Ridge, IL 60068

Address Newsletter editorial comments, questions, letter, and suggestions to:

John H. Eichhorn, M.D. Editor, APSF Newsletter; Dept. Anesthesia

Beth Israel Hospital, DA-7 1 7 Boston, MA 02215

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